_{Disclaimer: The following information does not take into account YOUR individual circumstances. To discuss the option of VBAC further, please see your care provider. The author accepts no responsibility for any adverse outcomes in relation to the following information.}

Are you interested in homebirth, but unsure if it is safe because you have had one or more previous caesarean sections?

Relax...homebirth can still be a safe option for you - and has been for many women. You just need to work your way through the available research in order to explore the option more fully, in relation to your personal circumstances. Only then will you be able to make truly informed decisions regarding a home birth after caesarean/s.

As well as that, I suggest reading a copy of "What Every Pregnant Woman Needs to Know About Caesarean Section" available from http://www.childbirthconnection.com/article.asp?ck=10164  . Also, make sure you have a read the recent 2006 systematic review of the evidence comparing Vaginal Birth After Caesarean (VBAC) to repeat caesarean section: "Vaginal Birth and Cesarean Birth:How Do the Risks Compare?" which is also available on that same page at childbirthconnection.com  . This review included over 300 research reports on VBAC. It concludes: "Over a wide range of probabilities, planned vaginal birth after caesarean section is (mathematically) the safer choice. Morbidity associated with successful vaginal birth is about 1/5 that of elective caesarean section".

The "Tips & Tools" page is also fantastic on that site: http://www.childbirthconnection.com/article.asp?ClickedLink=298&ck=10214&area=27

(FYI: Childbirth Connection is a US based organisation which was founded in 1918. They conduct systematic reviews of research findings from the most high-quality scientific research articles and publish them on the Cochrane Database; comparing, contrasting and collating the results of these articles and then formulating summaries of the evidence. The Cochrane Database is respected in medical and midwifery fields as the gold standard for the most up to date, reliable evidence to use in policy making. Childbirth Connection updates their web pages regularly and also publishes a book called "A Guide to Effective Care in Pregnancy and Childbirth" - which summarises the results in easy-to-understand everyday language.)

Having A Vaginal Birth After One, Or More Than One, Previous Caesareans - Evidence Based Decision Making During Care Planning

Vaginal Birth After Caesarean (VBAC) has been researched and reviewed time and time again with countless published studies over the years concluding that vaginal birth after caesarean is a safe option for most women. If you have only had one previous caesarean and your care provider will not even discuss or explore the option of VBAC in relation to your individual circumstances, then your care provider is out of touch with current evidence-based practice. On the other hand, for those who have experienced more than one previous caesarean section, it is a new concept to discuss the option of a vaginal birth (VBA2C), due to the limited amount of research that has been available for practitioner use. However, you will be pleased to know that on the whole, the current research which IS available, is actually quite positive and does support vaginal birth after more than one caesarean section.

RECENT STUDIES:

Vaginal birth after Caesarean section: an Australian multicentre study. VBAC Study Group.

Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permezel M...." In women attempting vaginal delivery after a previous lower segment Caesarean section, the uterine rupture rate was estimated at 0.3%, with 0.05% experiencing a perinatal death and 0.05% requiring a hysterectomy. Although VBAC rates in Australia remain lower than many overseas reported series, rates are increasing. While rupture continues to be associated with serious adverse outcomes, the incidence of rupture during trial of labour is low and appears to be associated with a better outcome than rupture of an unscarred uterus."    Aust N Z J Obstet Gynaecol. 2000 Feb;40(1):87-91.

The following are the main points from my presentation at a multidisciplinary conference in 2008 at the Gold Coast.

Why is the caesarean section rate higher than ever and rising? (Source: http://www.childbirthconnection.com)

• Under-use of care known to enhance birth eg continuity of known carer, labouring upright, moving, being well nourished throughout labour
• Side effects of interventions during labour eg epidural, continuous monitoring (CTG), induction or augmentation of labour
• Fear - experienced by the health care practitioner eg time constraints, not seeing much normal birth in their training
• Defensive medicine - thinking a caesarean section may reduce their risk of being sued
• Failure to offer the choice of VBAC - hospital policy or personal preference of the individual care provider
• Loss of skills in vaginal birth eg vaginal breech birth, twins
• The perception that caesarean section is safe (note that the mortality rate of caesarean section is four times higher than normal vaginal birth)
• Fear of childbirth by the women themselves

Tips for women for success in avoiding unnecessary caesarean section or assisted vaginal birth (Source: http://www.childbirthconnection.com)

• Find a doctor or midwife with low rates of intervention
• Discuss your goals and preferences with your caregivers
• Choose a birth setting with low overall rates of interventions
• Create your own birth statement / birth plan
• Arrange for continuous labour support from someone with experience
• Explore your options for pain relief
• Work with your caregivers to delay going to the hospital
• Receive good support throughout labour
• If possible, avoid continuous monitoring (CTG or EFM)
• Avoid epidural anaesthesia
• If possible, avoid being induced or augmented

Factors to Consider in the Decision of VBAC or VBA2C (Source: http://www.childbirthconnection.com)

• Risk Factors In Relation To Your Scar
- Vertical scar on uterus (high), inverted T or J shaped scar
- Previous uterine surgery (other than for the caesarean section)
- Previous uterine rupture AND it caused problems
- Bicornate or Septate Uterus
- Area of scarred Uterus - 2.5mm thick or less on late pregnancy ultrasound scan
(8-12% of women with above factors - scar gives way)
- Single layer suturing

• Relative Risk of Uterine Rupture in Relation to the Size of the Baby
- More than 4kg ?macrosomic ?more pressure on the scar- studies do not prove this
• Risks of Uterine Rupture in Relation to Being Post term?
- Beyond 40 weeks pregnant? - no strong evidence
• Risks of Uterine Rupture in Relation to Carrying Twins?
- Limited evidence but so far no increase in scar problems
• Risks of Uterine Rupture in Relation to Your Baby Being Breech?
- Limited evidence but so far no increase in scar problems
- ECV (External Cephalic Version - a procedure where the experienced practitioner attempts to turn the baby late in pregnancy) is safe with no increase in risk to scar
• Have You Had a Previous Vaginal Birth?
- If yes, you are statistically more likely to succeed without complications
• What Was the Reason for Your First Caesarean Section?
- Previous dystocia (eg shoulder dystocia - where the baby needed assistance from your care provider in order for you to birth the shoulders) is not a contraindication for VBAC. VBAC is still an option.
• What Was the Baby's Gestational Age At the Time of Your Previous Caesarean Section?
- Before 26 weeks of age there is a question of whether it was a true "lower segment caesarean section" (LUSCS) because at this gestation, the lower segment is poorly formed - therefore, you may have been cut through the body of the uterus rather than the lower segment.

• More than one previous caesarean section?
• Mother's age over 30?
• Uterine infection after the previous caesarean section?
• Due date less than 18 months after the previous caesarean section?
- 96-98% of these women will labour without a scar problem

• More than one previous caesarean section?
- "Evidence does not suggest that a woman who has had more than one caesarean should be treated any differently from the woman who has had only one caesarean section". (Enkin: 2000)

• Hospital Policy? Eg. Routine interventions, anaesthesia, induction / augmentation, continuous monitoring, epidurals
• Mother's and Baby's physical health?
• Is mum a smoker? Eat well? Sleep well?
• Any other health conditions?
• Does baby otherwise appear healthy on ultrasound scan?
• Continuity of Carer?

• Mother's Emotional Health?
- High Oxytocin levels? (Oxytocin is the "hormone of love" and in labour; produces effective uterine contractions; decreases anxiety, blood pressure, heart rate and the perception of pain; increases placental perfusion and fetal oxygenation; leads to a higher likelihood of normal birth. For more information see http://www.sarahjbuckley.com)
- Fear of birth? (Leads to increased requirement for pain relief, prolonged difficult birth and request for caesarean section (Alhagen et al (2001), Johnson & Slade (2002) Johnson & Slade (2003) ).
- Previous birth trauma? (For more information, see birthtalk.org)
- Support?
- Place of birth?

More than one previous caesarean section? (Source: http://www.childbirthconnection.com  )

• Mother - at increased risk of:
- Placenta praevia (mod to high risk)
- Placenta accreta / adhesion (mod risk)
- Placental abruption
• Baby - at increased risk of:
- Preterm birth
- Low birthweight
- Physical abnormality
- Brain / spinal cord injury
- Still birth
Note: These risks are increased regardless of how you decide to give birth - they are risk factors that could be investigated and if possible, ruled out before birth or monitored closely antenatally.

Uterine Rupture

• The probability of requiring an emergency caesarean section for other acute conditions (fetal distress, cord prolapse, APH), is up to 30 times as high as the risk of uterine rupture with a planned VBAC (Enkin:2000)
• The incidences of where the scar gives way: 2.7 in 10,000 (0.027%) - nearly 400 women need to have a repeat caesarean section in order to prevent 1 uterine rupture (http://www.childbirthconnection.com  : 2008)
• Baby death due to uterine rupture: 1.4 in 10,000 (0.014%) - you need to have over 7100 repeat caesareans in order to prevent 1 baby's death. (http://www.childbirthconnection.com  : 2008)

"Uterine Rupture: A 10-year population-based study of uterine rupture"
• A 10 year (1988 -1997) population based review of 114,933 deliveries in one province. 11,585 (10%) had had a previous caesarean section. 4,516 had a "trial of scar" (4%)
• Rate of Scar Dehiscence: 5 per 1000 VBACS (25% of these were induced or augmented)
• Rates of Complete Rupture: 3 per 1000 VBACS (50% of these were induced or augmented)
• No Maternal deaths but 1 neonatal death attributed to uterine rupture
• Conclusion: Induction and augmentation of labour are confirmed as risk factors for uterine rupture. Fetal heart abnormality was the most reliable diagnostic aid. Serious maternal perinatal morbidity was relatively low.

Obstet Gynecol 2001 Apr;97 (4 Suppl 1):S69
Baskett TF, Kieser KE
Dalbousie University, Halifax, Nova Scotia, Canada

The American College of Obstetricians and Gynecologists: 1999 state:
"The most common sign of uterine rupture is a non-reassuring fetal heart rate pattern with variable decelerations that may evolve into late decelerations, bradycardia, and undetectable fetal heart rate. Other findings are more variable and include uterine or abdominal pain, loss of station of the presenting part, vaginal bleeding, and hypovolemia".

What is Required from Care Providers in Order to Improve care for Women Having a VBA2C?

• Improved emotional support for the woman and her family (relationship based maternity care)
• Improved access to evidence-based information and resources
• Personalised, individualised care
• "Physiologically aware" environment eg. dark, warm, private
• Have a positive outlook
• Promote VBAC

_{(COPYRIGHT: A CODEGA: 2008)} 
 

More Research Articles on VBAC after More Than One Caesarean:

Note: These articles do not take into account the model of care which the women received.

• For those who have had more than one caesarean section; overall the vaginal birth success rate is little different from women who have had only one previous caesarean section (Enkin:2000)

• Rates of scar dehiscence are slightly higher but tended to be asymptomatic without serious sequelae (Enkin:2000)

The following story was posted on a bubhub birth forum:

... just think for a minute. If you were in a terrible car
accident and had to have a piece of metal removed from your leg (sorry
for the visual there, ugh) .... say they had to cut in to get it.
Then they stitch you all back up. What do you expect the scar to do?
Do you expect it to fall open when you start to walk? No? Well, okay
maybe normal walking is okay, but what about running? Maybe running
will cause it to fall open. No? Alright maybe not normal running, but
I bet a marathon would cause enough pressure to just rip it open,
right? Hmmmm ... wait a second, maybe not. Perhaps if they hooked the
repaired leg up to a machine that mimicked running, it could cause
problems ... esp a machine that pulled the muscle further than normal
use would, that didn't do it "naturally" (kind of like pitocin!). But
for regular use, we expect ourselves to stay shut. We expect wounds to
have healed. We expect normal function to be obtainable for
straightforward injuries.

If we get a cut or have stitches anywhere else on our bodies, we expect
it to stay shut. If we looked at the doctor and said, "I don't think
this is going to stay shut", they would be highly offended because we
were doubting their skill as a surgeon AND we would be turning our
noses up at our body's ability to heal and reams of scientific evidence
that it does.

But then when we have a c-section, we look at that and think, OH NO
this thing isn't going to hold!!! Do you think the surgeon stitched
you up? Do you think s/he is a skilled surgeon? If your old surgeon
questions the integrity of your healing, then he or she is expressing a
complete lack of confidence in his/her work. Point that out. They
need to think about this. If your new OB or midwife is questioning the
integrity of your womb, then they need to be confronted about doubting
the surgical skill of your previous surgeon. If they doubt his or her
skill that seriously, perhaps they need to express their concern to the
medical board.

Anytime someone is stitched back together the ultimate goal is to
prepare the organ or muscle or whatever to perform its normal function.
I have had 2 c-sections. One was with my first and one was with my
fifth. The rest have been hbacs. All my births up through the second
c-section were to fairly tiny babies, weighing between 6.5 and 8
pounds. My sixth ... the fresh vbac who was testing out the surgeon's
skill ... was 11 pounds 4 ounces. I had some nifty pushing
contractions. And I can compliment my surgeon for a job well done
because her work held up under Normal Use. Giving birth is Normal Use,
yes even when giving birth to an 11 pounder. It is exactly what the
uterus was created to do. If we expect that a straightforward incision
and stitching should restore other muscles to regular use, then why do
we doubt the womb?

I will tell you what finally set my own mind to ease this last pg
because yes for the first time ever, I was actually nervous about UR
(something about hanging around ICAN where it is talked about all the
time, lol ... fear started rubbing off there!). My daughter used to
play with my LUS ... she would push and stretch and wedge herself in.
She would shove her hands right under where my external incision scar
was and do boxing drills. Maybe she could feel the ridge of my
external incision? I don't know. But what I do know is that I felt
very reassured that if she could do all that and it held together, then
what was a little labor?

VBAC resources online

Caesarean Awareness Network Australia
http://www.canaustralia.net  

Birthtalk.org (Support group in Brisbane also offering a VBAC antenatal class)
http://www.birthtalk.org  

Caesarean Awareness Recovery Eduction Support
http://www.cares-sa.org.au  

Birthrites
http://www.birthrites.org

International Caesarean Awareness Network
http://www.ican-online.org  

Rebuttal to Rationales for Denial of VBAC
http://www.hencigoer.com/articles/vbac/

Caesarean Info (In the Interest of Prevention)
http://www.motherstuff.com/html/midwife-cesarean.html  

Summary of the Four Largest and Most Recent VBAC and Elective Repeat Caesarean Studies
http://www.storknet.com/cubbies/vbac/4studies.htm  

Vaginal Birth after Caesarean Checklist
http://www.childbirth.org/section/VBAC.html  

Two or more previous caesareans?
http://www.homebirth.org.uk/vba2c.htm  

Vaginal Birth after 2 or More Caesareans
http://www.plus-size-pregnancy.org/CSANDVBAC/vbac_after_2_cs.htm

VBAC.com
http://www.vbac.com  

Online support for home birth after caesarean birth
http://www.egroups.com/community/HBAC  

Maternity Wise
http://www.maternitywise.org  

Northern New England Perinatal Quality Improvement Network (VBAC consent forms, data, risk benefit statements, practice guidelines, VBAC stories) http://www.nnepqin.org/ViewPage?id=6  

CLICK HERE to be directed to a HBA3C Birth Video

CLICK HERE to be directed to a HBA2C Birth Video